Provider Demographics
NPI:1336870914
Name:CARLSON, KELLI ANN (NCC, TLMHC)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:ANN
Last Name:CARLSON
Suffix:
Gender:F
Credentials:NCC, TLMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2711 W 63RD ST
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52806-1647
Mailing Address - Country:US
Mailing Address - Phone:563-388-1039
Mailing Address - Fax:
Practice Address - Street 1:2711 W 63RD ST
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52806-1647
Practice Address - Country:US
Practice Address - Phone:563-388-1039
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-23
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA120838101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health